Missed opportunities by police contacting rail operators, who in turn place too much emphasis on their rule book, led to the death of a student struck by a train near Willesden, an inquest heard.

Devante Keane, 20, was struck by a Chilterns Railway train near Dartmouth Road, following a 40 minute chase by police that could have given signallers time to tell the driver to stop.

North London Coroners Court heard how the Metropolitan Police alerted London Underground but not Network Rail that there was a person on the tracks and the lack of effective communication between all groups led to Mr Keane’s death.

Coroner Andrew Walker said: “There were lost opportunities to contact the railway companies.”

He added: “The train driver would have been able to stop his train before the train struck Mr Keane.”

Mr Keane, from Essex, broke free from two officers in November 2013, who stopped him on Christchurch Road, believing he was smoking a joint.

Although no evidence of this was found, a post mortem revealed he had been ‘high on cocaine and cannabis’ at the time of his death and that his jacket contained 12 wrapped packages of Class A and B drugs.

No evidence of physical injury caused by Taser use, a baton strike or a dog bite that could have caused his death or disoriented him.

Coroner Andrew Walker surmised that containment by police, a police helicopter and police dogs led the student on to the track where he was struck from behind at 5.13pm.

The court heard from Network Rail that the train was in Rickmansworth at 4.47pm.

Jason Perdie, operations manager with experience of signalling, said: “We would have been able to stop train and caution the driver in time.”

Mr Walker added conflicts with the rule book, from the Rail Safety Standards Board, a government body, added further difficulties. He reminded the inquest that if a train is in danger it can be stopped, but if a person is in danger, the train can only be cautioned (slow downed).

Mr Perdie said he understood the conflict saying: “If a request is made by the police, then depending on the circumstances we can stop the train.”

Extending his “deepest sympathies” to Mr Keane’s family, Mr Walker made recommendations that all railway lines in an area should have an automatic system of communication, and changes to the RSSB Rule Book “need to be cleared up.”

A spokesman for the police said: “Given the circumstances of the incident, the matter was referred to the Independent Police Complaints Commission who completed their assessment and were satisfied the investigation be dealt with by officers from the Met’s Directorate of Professional Standards.

Following a thorough investigation, one member of police staff received words of advice and additional training relating to procedures when dealing with incidents on, or close to, railway lines.

In addition, the MPS continues to work closely with National Rail to ensure rail maps used by police staff are up-to-date and clearly marked with both underground and overground lines.

The MPS is in the process of upgrading its IT system to ensure that correct railway lines can be identified quickly in the case of trespassers on the line.”

“A spokeswoman for RSSB said: “RSSB has received a recommendation from the coroner about changing the industry rule book and will discuss it with industry members”.

Cause of death: Narrative (The circumstances of a death are recorded without attributing the cause to a named individual).

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